University of Cambridge and Yale University researchers reported in the journal PLoS Medicine that the countries, which received IMF money between 1989 and 2005, experienced, on average, a 16 percent spike in TB death rates after accepting the financial aid followed by a 30.7 percent dip after the loans were paid off.

It is well-known that TB rates in these countries rose after the fall of communism. Less clear was why countries saw such different disease outcomes. The death rate doubled from 6.2 to 13.3 per 100,000 people between 1991 and 2002 in the post-Soviet republics. Mortality in the former communist states of eastern Europe, however, slid from 5.6 to 3.2 per 100,000, or about 40 percent.

One difference between the two groups was the amount of IMF debt incurred: the former Soviet nations had an average debt of $850 million and took an average of 10.3 years to pay back the loans. The eastern European countries incurred less debt—$270 million on average—which they repaid in an average of 5.5 years.

The researchers found that the size of the loan was proportional to the mortality rate. Deaths rose 4 percent for every year of repayment and 0.9 percent for every 1 percent increase in IMF lending. Slovenia, the only one of the 21 countries that did not take out IMF loans, saw the greatest decline in its tuberculosis mortality rate. All told, IMF involvement was linked to 1.6 deaths per 100,000 across the countries.

Public health organizations have long maintained that strings attached to IMF loans can have the effect of stifling a country's health care spending, which in turn may worsen health problems. "We've been hearing [that] for decades from our colleagues in Africa," says Joanne Carter, executive director of RESULTS Educational Fund, a Washington, D.C.–based public health advocacy organization. The new study marks the first scientific look at that claim.

The IMF was formed in 1945 to give financial aid to countries seeking to adopt market economies or in times of economic crisis. It currently has 185 member nations, including the U.S. and Russia, which have contributed a combined $300 billion in funding.

When it makes a loan, the IMF may impose certain terms such as requiring that a country reduce overall government spending by a certain amount. Murray says the IMF tailors the terms of a loan to the country and that it would never counsel a recipient of one of its loans to cut back on health spending.

A 2007 report by the Center for Global Development, a Washington, D.C., policy think tank, however, concluded that the terms of IMF loans limit countries' options for cutting spending and that it has too frequently imposed limits on total wages that governments can pay to doctors and other public workers.

Researchers chose the post-communist countries for this study, because they kept detailed records of tuberculosis cases, and the number of cases had been falling until the 1990s. At around the same time, many of the countries began taking out loans from the IMF.

Murray says nations that received IMF money did so because they were in dire financial straits, which is why they would have had high rates of tuberculosis.

Which came first? David Stuckler, a Cambridge health economist and epidemiologist and lead author of the new study, says he and his colleagues found no evidence that TB rates were rising before countries took out their loans. They also found that changes in gross domestic product (GDP), a measure of economic output, could not account for the change in TB deaths. "It wasn't just one correlation," Stuckler says. "We applied a battery of tests to see if our finding could withstand them."

The proposed link is plausible, says epidemiologist Megan Murray of Harvard University, co-author of a commentary on the paper in PLoS Medicine. "There has been a lot of criticism of the IMF from health activists and others," she says. "Our point was that there was a need for evidence and studies such as this one that actually look at the data."

The World Bank, the IMF's sibling organization, reported last year that the rising incidence of tuberculosis and, in particular, a drug-resistant variety, can actually damage a nation's economy because it is so costly to control.

The tuberculosis bacterium kills an estimated 1.5 million people globally every year. If left untreated, it can cause death within 18 months. The World Health Organization (WHO) recommends a treatment regimen known as directly observed therapy, short-course (DOTS), which consists of four antibiotics taken under medical supervision for six months.

Stuckler says the disease is considered an overall indicator of a population's health, "If you see tuberculosis rates rise, you expect bad things to come," he says. "Mortality is an immediate response to inadequate access to care." Improper treatment is also believed to be the primary reason why strains of the bacterium have emerged that are highly resistant to antibiotics.

The problem is not limited to a single country, as was demonstrated last year by the case of Andrew Speaker, an Atlanta lawyer diagnosed with extremely drug-resistant TB who boarded an international flight from Rome to Montreal and drove across the U.S. border despite warnings by U.S. health officials.

Stuckler says it is worth thinking about the best way for the IMF to proceed. "It's not the case that medical mismanagement in Russia only matters there," he says. "Tuberculosis has wings."

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